Family Practice

This Article Abstract FREE Full Text (PDF) E-letters: Submit a response Alert me when this article is cited Alert me when E-letters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to citation manager Search for citing articles in: ISI Web of Science (13) Request Permissions Google Scholar Articles by Frenkel, M. A Articles by Borkan, J. M Search for Related Content PubMed PubMed Citation Articles by Frenkel, M. A Articles by Borkan, J. M Social Bookmarking          What's this?

Family Practice Vol. 20, No. 3, 324-332
© Oxford University Press 2003

Models of Care

An approach for integrating complementary– alternative medicine into primary care

Moshe A Frenkel and Jeffrey M Borkan^a

Complementary and Traditional Medicine Unit, Department of Family Practice, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa,
^a Department of Behavioral Sciences, Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel and Department of Family Medicine, Brown Medical School, Providence, RI, USA.

Correspondence to Moshe Frenkel, MD, Hashoftim 1 B, Zichron Yaacov, Israel; E-email: frenkelm{at}netvision.net.il

Frenkel MA and Borkan JM. An approach for integrating complemetary–alternative medicine into primary care. Family Practice 2003; 20: 324–332.

	Abstract

Top Abstract Introduction Methods Suggested strategy for... Conclusion References

 
Background. Despite family practitioners frequently being requested to assist their patients with advice on or referrals to complementary–alternative medicine (CAM), there is an absence both of evidence about the efficacy of nearly all specific treatments or modalities and of guidelines to assist with the integration of conventional and CAM therapies.

Objective. The aim of this article is to suggest a comprehensive and rational, best-evidence strategy for integrating CAM by primary care practitioners into primary care, within the context of the limitations of the current knowledge base and the local milieu.

Methods. The suggested approach was developed by a combination of literature review, key informant interviews, focus groups, educational presentations for family practice residents and practitioners, and field testing. An iterative model was utilized whereby more refined drafts of the suggested approach were subjected to later discussants and groups, as well as further field testing. Drafts of the strategy were utilized in consultations of patients requesting advice on alternative medicine in a primary care setting and in a CAM clinic.

Results. Both family physicians and CAM practitioners provided useful comments and recommendations throughout the process. These can be categorized in terms of knowledge, attitudes and skills. Our strategy suggests that patients requesting advice on the use and integration of CAM modalities as part of their health care should be evaluated initially by their primary care physician. The physician’s responsibilities are to evaluate the appropriateness of that use, and to maintain contact, monitoring outcomes. Advice on referrals should be based on the safety of the method in question, current knowledge on indications and contraindications of that modality, and familiarity and an open dialogue with the specific therapist.

Conclusions. Given patients’ demands and utilization of CAM therapies, despite the lack of evidence, there is an increasing need to address how CAM therapies can be integrated into conventional medical systems. These suggestions should respond to patient’s expectations and needs, but at the same time maintain accepted standards of medical and scientific principles of practice.

Keywords. Alternative medicine, clinical guidelines, complementary medicine, family practice, integrative medicine.

	Introduction

Top Abstract Introduction Methods Suggested strategy for... Conclusion References

 
Complementary–alternative medicine (CAM) is becoming increasingly popular worldwide. In Western Europe and Australia, 20–70% of the population regularly use complementary and alternative medicine.^1,2 In the USA, it was estimated in 1992 that at least one in three Americans utilized one of those methods, and the number of annual visits to providers of alternative medicine exceeds the number of visits to all primary care physicians.³ These therapies include acupuncture, chiropractic, herbal medicine and dietary supplements, nutriceuticals, homeopathy, mind– body techniques, spirituality and faith healing, massage, therapeutic touch and a number of others. In a 1998 follow-up study, the percentage of CAM patients had increased to 42% of the US population.⁴ Subsequent analyses showed that 67.6% of respondents had used at least one CAM therapy in their lifetime. This trend suggests a continuing demand for CAM therapies that will affect health care delivery for the foreseeable future.⁵

Paralleling and even exceeding the growth in utilization of CAM is the surge in information available to the public in the media, health food stores and the Internet. Faced with this cacophony, patients are often left with a desire for guidance and direction. Family physicians may be a source of such knowledge and are turned to frequently by some of their patients seeking advice. Others are more wary of reactions by their physicians and may avoid disclosure of the CAM methods that they incorporate into their health care.^4,6–8 In a study of patients with recently diagnosed breast cancer who had combined CAM in their health care, subjects tended to anticipate negative responses from the physician or detected an impression of disinterest.⁶ The patients in this study made it clear, however, that they value their physician’s understanding regarding treatment choices even in the absence of agreement. They appreciate physicians who were respectful, willing to listen and open minded. Medical educators also increasingly realize that there is a need to respond to this challenge.^9–14 Medical schools as well as family practice residency programmes have started to add courses involving complementary and alternative medicine.^15–17 A survey among US medical schools found that 64% of the schools offered at least an elective course in CAM or included these topics in required courses.¹⁵ About one-third of these courses were offered by departments of family practice.¹⁷

Despite all the demand and interest in CAM, there remains a distinct lack of evidence regarding efficacy. Even though there exists more CAM research than is commonly recognized, until recently, most of the research has been of poor quality, and the majority was conducted in Europe and published in non-English language journals. Nonetheless, in the past few years, there has been an increase in quality and quantity of research in this area. The Cochrane Library lists >5300 reports of randomized trials and >60 systematic reviews on CAM. A Medline search using the terms ‘alternative medicine’ or ‘complementary medicine’ reveals >80 000 citations. The NIH Center of Complementary and Alternative Medicine has collected a database of nearly 100 000 citations from conventional databases. Although much of the research has failed to show effects, there are an increasing number of studies that support the use of some CAM modalities for particular indications. Examples include the use of acupuncture for primary dysmenorrhea¹⁸ or homeopathic treatment for chemotherapy-induced stomatitis,¹⁹ allergies²⁰ or migraine headaches,^21,22 and other studies that highlight the potential dangers in utilizing certain CAM treatments.^23–27

Developing a proper dialogue between the CAM practitioner and the physician is a neglected topic in the medical literature, even though it is essential to the process of integration. Communication between the CAM practitioner and the physician requires a combined effort on the part of both parties to develop a common language.^28,29 A report of a successful model of complementary practitioners as part of the primary health care team was published recently.^30,31 This model encourages communication and collaboration between team members, conventional and complementary practitioners, and was successful in preventing conflict over main issues of power, control and decision making.

Despite a few attempts, it has yet to be established how to integrate CAM therapies into the conventional medical system in a systematic way. A logical first step in this direction of integration is to establish guidelines for the proper integration of CAM into primary care, supported by appropriate research and clinical experience. Unfortunately, the research data on this issue are quite limited. Recently, in the USA, the Federation of State Medical Boards developed and adopted new model guidelines for the use of complementary and alternative therapies in medical practice.³² This document provides recommended guidelines for State Medical Boards to use in educating and regulating physicians who use CAM in their practices or co-manage patients with State-regulated CAM providers. These guidelines also suggest an organizational structure for the integration of accepted standards of care with legitimate medical uses of CAM. In Great Britain, trials of integration of CAM were mentioned in BMA guidance for GPs on referrals to CAM practitioners, which provide an important source of reference relating to referral patterns.³³ However, this document relates primarily to the British system of health care and is narrow in scope. It does not touch important issues related to the integration of the proper evidence on CAM efficacy and safety, appropriate patient triage, selection of CAM providers, communication issues with patients and CAM providers, and other issues involved in the integration process.

	Methods

Top Abstract Introduction Methods Suggested strategy for... Conclusion References

 
The suggested strategy for integrating CAM into clinical practice (see below) was developed by a combination of literature reviews, key informant interviews, focus groups, educational presentations for family practice residents and practitioners, and field testing. Except for some of the educational presentations, all work was conducted in Israel.

The initial draft of suggested strategy was developed in the authors’ clinical practices and arose out of the necessity to provide rational guidance to patients on referral and utilization of CAM services. The clinical settings included two types of clinical practices. The first was a practice composed of 10 small rural family practice clinics where the authors (JB and MF) were the sole family practitioners. Patients in these practices frequently utilized CAM therapies in addition to their conventional treatments, and many patients felt sufficiently comfortable both to discuss their use and to request non-judgemental advice. The second clinical setting was an urban multispecialty CAM clinic in which one of the authors (MF) served both as a triage physician and as a director. In these capacities, he had two major tasks:

1. To verify that there was no contraindications to the use of CAM therapies, or need for further evaluation or treatment by conventional methods.
   
2. To help patients choose the treatment modality that best suits their condition, and to provide follow-up to monitor both treatment side effects and outcomes.
   

The development process started with a review of both the conventional and CAM literature^34–41 followed by discussions with ‘key informants’ and clinical observations. Input came from staff meetings in the CAM clinic (staff of 18 providers), observations of experiences and outcomes among CAM users, and discussions with other physicians and CAM providers on their experience with CAM use among their patients. An interactive, iterative feedback and development loop was established whereby drafts of the suggestions were implemented and continually tested in the authors’ practices—both in family practice settings and in a referral CAM clinic—as well as presented and discussed with individuals and groups. Eight educational forum focus groups were conducted among family practice trainees and specialists in Israel (six groups) and the USA (two groups) After presentation of the background on CAM, the suggestions and clinical examples, the participants were asked for oral and/or written comments about the suggestions. Sessions lasted between 1 and 2 h, and nearly 90 specialists and trainees took part in these activities. Field notes of the groups’ comments were kept for analysis. Additional key informants, authorities in either CAM or primary care, were also interviewed at length in order to increase the accuracy, usefulness and content validity of this approach. Their comments were incorporated into later versions of the suggestions.

Clinical field testing occurred throughout the course of suggestions development. This testing involved patients both in primary care at sites in northern and southern Israel, and at a CAM clinic. Given the range of medical problems and the continued process of changes, no outcome data were collected. In this case, the template was the draft of the suggestions as they stood at the time. Thus, each group worked later and more refined iteration.

Data analysis
The analytic core of this study is a qualitative iterative cycle of data collection, analysis, refinement of the research questions and clinical strategy, leading to further data collection. This cycle was repeated by the authors until interpretations were formulated and verified. ‘Immersion/ crystallization’ was the major data analysis method. This involves, "the analyst’s prolonged immersion into and experience of the text and then emerging, after concerned reflection, with an intuitive crystallization of the text".⁴² Over the 5 years of development, the approach strategy was utilized as the central working document. Searches for alternative interpretations and negative cases were also stressed as part of the analytic process.

Findings
A full presentation of the findings from the range of literature reviews, key informant interviews, focus groups, educational presentations and field testing is beyond the scope of this article. Table 1 provides a snapshot of types of information and reactions received from both family physicians and CAM providers, categorized by its relationship to ‘knowledge, attitudes and skills’. The chief product of the research effort and the central working document, the suggested approach for integrating CAM into primary care, is presented below. These suggestions are only an initial step in approaching this issue in a balanced, logical and educated approach. The approach relates to the three parts of this new therapeutic triangle:

View this table: [in this window] [in a new window]   TABLE 1 Example of responses to the integration of CAM into primary care

 

1. The patient
   
2. The CAM provider
   
3. The physician.
   

	Suggested strategy for integrating CAM into primary care

Top Abstract Introduction Methods Suggested strategy for... Conclusion References

 
The patient
Patients tend to avoid disclosing CAM use in the medical encounter. They tend to anticipate a negative response from the physician or give an impression of disinterest that is being reflected from the physician. Others believe that physicians are unable or unwilling to contribute useful information or have a perception that disclosure of CAM use is not relevant to the conventional treatment that they receive at the same time. On the other hand, patients value their physician’s respect and understanding regarding treatment choices even, at times, in the absence of agreement. They appreciate physicians who are respectful, willing to listen and open minded.^6,8

One can conclude that the first step in considering integration between CAM and conventional medicine is fostering open communication and creating a non-threatening environment in which patients can feel comfortable about disclosing CAM use and seeing the physician as an ally in their treatment choice. Such an approach may avoid the reticence patients often have in disclosing CAM use to their physicians during medical encounters.^4,6–8 Discussing patients’ preferences and expectations will clarify the reasons patients seek CAM, and provide clues for improving the integration of CAM into their conventional health care. Just asking about CAM has been shown to be instrumental in discussing such issues.^43,44

Helping patients select a CAM modality requires a subtle balance between patient preferences, characteristics of the disease or entity to be treated, and the available evidence about the efficacy and safety of the CAM modality. Patients who feel comfortable discussing CAM use with their physicians tend to bring the physician multiple information sources. These may include something they read in the newspaper, heard from a friend, relative or from the local health food store, searched on the Internet or explored through other means. Others come to the physician with the expectation of receiving general advice about CAM use for their specific condition, without any knowledge about a specific CAM modality. The majority of those who use CAM do so because they find these health care alternatives to be more congruent with their own values, beliefs and philosophical orientations toward health and life.⁴⁵ They may expect their family physician to be their informed consultant who can provide them with a balanced approach: an approach that utilizes knowledge of a safe and effective treatment that relates to their medical history, medical condition and the medications that they use, but at the same time sensitive to their values and beliefs. To come to a successful integration of CAM, there is a need to empower the patient and involve him or her in the decision process. The patient expects the physician to share his findings with him, discuss the advantages and disadvantages of using the specific CAM modality in question, and come to a mutual decision about the safe integration of CAM in his health care.

The CAM provider
Once a treatment modality has been chosen by the patient and his or her physician, the next step is finding the right provider. Patients need to consider accessibility, length of an average treatment session, cost and the expected number of treatment sessions. However, an important part of this selection process is the verification of the professional background of the CAM provider. In the USA, increasing numbers of states are beginning licensure for CAM providers. In the recent guidelines released by the Federation of State Medical Boards of the USA, the suggestions are that referral should be made to a licensed or otherwise state-regulated health care practitioner with the requisite training and skills to utilize the CAM therapy being recommended.³² In those regions where licensure is not required, one can consider school attended, duration of study, certification and membership of a professional society. Recommendations from patients and professional colleagues are time honoured if imperfect.

For the physician, it is essential to work with providers who are amenable to open communication and perhaps even consider co-operative care of patients. Qualified therapists should be able to identify the conditions they feel that would respond well to their treatment modality, as well as those that will not. At the same time, they should be able to discuss their limitations with the patients’ medical problems and situations they would feel uncomfortable treating or would refuse to treat. It seems important that each physician should develop his own list of trusted CAM providers in his community. This list should include providers that the physician feels comfortable co-operating with, and this usually can be accomplished after meeting and screening these therapists in their office. Communicating and collaborating with complementary practitioners is an essential part of the process of integration of CAM into the primary care setting. Working as a team in which both primary care practitioner and CAM practitioner work together, consulting with each other openly, and maintaining a high degree of professionalism, will be in the patient’s best interests. By putting some effort into improved dialogue and communication, one can overcome the Tower of Babel effect,²⁹ a common situation in which the two schools of thought, conventional medicine and CAM, are talking two separate languages, and one cannot understand the other. Overcoming this communication gap can lead to learning a common language that can produce a true collaboration.

The physician
Patients requesting advice on the use and integration of CAM modalities as part of their health care should be evaluated initially by their family physician. This initial evaluation should clarify that the patient does not fall into any of the following three categories:

1. the patient is facing a life-threatening illness (e.g. meningitis, pneumonia, appendicitis, trauma, fractures, etc.);
   
2. a situation that requires further evaluation that has the potential to uncover diagnosis of a life-threatening illness (e.g. bloody stools, haemoptysis, weight loss, etc.); or
   
3. an illness for which conventional medicine has a clear and effective therapy (e.g. treatment of certain cardiac conditions, hypothyroidism, diabetes, parasitic infections, iron deficiency, anaemia, etc.).
   

Such monitoring requires a detailed history, physical exam and appropriate lab work if needed. After this initial and crucial task, the physician’s responsibility is to evaluate the appropriateness of CAM use. Advice on referrals should be based on the safety of the method in question, current knowledge on indications and contraindications of that modality, and familiarity with the specific therapist.

The first principle, as in all of medicine, is primum non nocere—first do no harm, and applies here as in any other field of medicine. Any treatment modalities should be, first of all, safe to use and carry minimal risk for adverse effects. Some therapies, such as certain herbs, can be potentially dangerous,^23,24 or might be dangerous when combined with the conventional treatment that the patient is already using.^25,26 One has to be aware that adding another therapeutic element requires us to have knowledge of possible interactions between conventional drugs that the patient is already taking and the CAM treatment.⁴⁶ A common example is the use of the herb Ginkgo Biloba, commonly used for dementia. This herb can interact with warfarin. This combination can increase bleeding tendency, and requires extreme caution.²⁶

As with any field in medicine, physicians have to educate themselves regarding the new treatment modality prior to utilizing it. CAM therapies are no exception. The consultation process is quite complex. Physicians need to consider their patient’s medical condition and history, the medications that they use and any sensitivities in this selection process. The estimated number of CAM modalities exceeds 100, as well as thousands of nutritional supplements and herbs available in natural pharmacies and health food stores. One has the task of sorting out the safe and effective therapies from the myriad of those available. This process makes both the patient and the physician confused as to which treatment to choose. In addition, there is the need to base the recommendation on evidence from the medical literature, applying the same principles of evaluation of any therapy that one may want to incorporate into their practice. Unfortunately, few CAM modalities have the level of evidence that would be required routinely for many conventional treatments.

Nonetheless, more and more literature of sufficient quality is appearing weekly. Searching Medline is the first source for obtaining clues on the specific modality, herb or supplement in relation to the condition needed to be treated. Secondary sites that contain meta-analyses can be found at the Cochrane Collaboration and other sites⁴⁷ (Table 2). When these are not present or are insufficient, one can go on to cross-referencing, utilizing some of the references mentioned in the bibliography,^46–59 as well as other on-line sources (Table 2).

View this table: [in this window] [in a new window]   TABLE 2 Reliable on-line sources for CAM

 
With this information in hand, the physician can suggest a CAM method that is safe and has the best chance, according to the literature, of improving the health of the patient. However, if the CAM therapy carries risk or possible adverse interactions, the physician has the responsibility to persuade the patient that this specific CAM method should not be used in the specific situation due to known side effects, drug interactions or other causes.⁹ Similarly, if the modality has been clearly shown to be ineffective, the physician may be compelled to caution the patient.

Having the proper information is only part of the process. To achieve a successful integration of CAM, there is a need to empower the patient and involve him or her in the decision process. The physician should share his findings with the patient, discuss the advantages and disadvantages of using the specific CAM modality in question, and come to a mutual decision about the safe integration of CAM in the patient’s health care.

It is also important to verify patients’ expectations from the therapy. Some expect miracles in one visit, which rarely happens. Most of these treatment modalities require 6–12 visits, or 2–3 months of treatment; it could be shorter or longer depending on the severity and the duration of the discomfort. None of the CAM therapies is a perfect system; every method has its advantages and disadvantages. In the treatment plan, the physician should continue to play an active role and be in direct communication with the CAM provider. Also, as mentioned in the previous section, communicating and collaborating with complementary practitioners is an essential part of the process of integration of CAM into the primary care setting. The physician has the responsibility of the continual follow-up and assessment of progress at regular intervals.

In the case of undesired side effects, appearance of new symptoms and lack of progress or improvement, the physician has the responsibility to re-evaluate the patient and make a decision about the need to perform additional work-up, or to change the treatment modality. The process of integration is summarized in Figure 1.

View larger version (19K): [in this window] [in a new window]   FIGURE 1 Decision tree on CAM modality selection and integration

 

	Conclusion

Top Abstract Introduction Methods Suggested strategy for... Conclusion References

 
With the increased popularity of CAM, family physicians are faced with demands and questions related to the integration of CAM in their patient management. This article has attempted to take an initial step—providing a logical and comprehensive approach for the integration of conventional and CAM therapies in the primary care setting. This approach is patient centred, responding to patient’s expectations and needs, but at the same time designed to maintain accepted standards of medical and scientific principles of practice.

View this table: [in this window] [in a new window]   TABLE 3 Points in selecting CAM method

 

	References

Top Abstract Introduction Methods Suggested strategy for... Conclusion References

 
¹ Fisher P, Ward A. Complementary medicine in Europe. Br Med J 1994; 309: 107–111.[Free Full Text]

² MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569–573.[CrossRef][ISI][Medline]

³ Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, cost, and patterns of use. N Engl J Med 1993; 328: 246–252.[Abstract/Free Full Text]

⁴ Eisenberg DM, Davis RB, Ettner SL, Wilkey S, Van Rompay M, Kessler RC. Trends in alternative medicine use in the United States, 1990–1997. J Am Med Assoc 1998; 280: 1569–1575.[Abstract/Free Full Text]

⁵ Kessler RC, Davis RB, Foster DF et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med 2001; 135: 262–268.[Abstract/Free Full Text]

⁶ Adler SR, Fosket JR. Disclosing complementary and alternative medicine use in the medical encounter. J Fam Pract 1999; 48: 453–458.[ISI][Medline]

⁷ Eliason BC, Myzkowski J, Marbella A et al. Use of dietary supplements by patients in a family practice clinic. J Am Board Fam Pract 1996; 9: 249–253.[Medline]

⁸ Von Gruenigen VE, White LJ, Kirven MS et al. A comparison of complementary and alternative medicine use by gynecology and gynecologic oncology patients. Int J Gynecol Cancer 2001; 11: 205–209.[CrossRef][ISI][Medline]

⁹ McWhinney I. A Textbook of Family Medicine, 2nd edn. Oxford: Oxford University Press, 1997: 401–410.

¹⁰ Frenkel M, Ben Arye E. The growing need to teach about complementary and alternative medicine: questions and challenges. Acad Med 2001; 76: 251–254.[ISI][Medline]

¹¹ Grollman AP. Is there wheat among the chaff ? Acad Med 2001; 76: 221–223.[ISI][Medline]

¹² Marcus DM. How should alternative medicine be taught to medical students and physicians? Acad Med 2001; 76: 224–229.[ISI][Medline]

¹³ Sampson W. The need for educational reform in teaching about alternative therapies. Acad Med 2001; 76: 248–250.[ISI][Medline]

¹⁴ Konefal J. The challenge of educating physicians about complementary and alternative medicine. Acad Med 2002; 77: 847–850.[ISI][Medline]

¹⁵ Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving complementary and alternative medicine at US medical schools. J Am Med Assoc 1998; 280: 784–787.[Abstract/Free Full Text]

¹⁶ Ben-Arye E, Frenkel M. Between metaphor and certainty: teaching an introductory course in complementary medicine. Harefuah 2001; 140: 855–859.[Medline]

¹⁷ Brokaw JJ, Tunnicliff G, Raess BU, Saxon DW. The teaching of complementary and alternative medicine in US medical schools: a survey of course directors. Acad Med 2002; 77: 876–881.[ISI][Medline]

¹⁸ Helms JM. Acupuncture for the management of primary dysmenorrhea. Obstet Gynecol 1987; 69: 51–56.[Abstract/Free Full Text]

¹⁹ Oberbaum M, Yaniv I, Ben-Gal Y et al. A randomized, controlled clinical trial of the homeopathic medication Traumeel S in the treatment of chemotherapy-induced stomatitis in children undergoing stem cell transplantation. Cancer 2001; 92: 684–690.[CrossRef][ISI][Medline]

²⁰ Frenkel M, Hermoni D. Effects of homeopathic intervention on medication consumption in atopic and allergic disorders. Altern Ther Health Med 2002; 8: 76–79.[ISI][Medline]

²¹ Kleinjnen J et al. Clinical trials of homeopathy. Br Med J 1991; 302: 316–323.[ISI][Medline]

²² Linde K, Clausius N, Ramirez G et al. Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 1997; 350: 834–843.[CrossRef][ISI][Medline]

²³ Sheikh NM, Philen RM, Love LA. Chaparral-associated hepatotoxicity. Arch Intern Med 1997; 157: 913–919.[Abstract]

²⁴ Anderson IB, Mullen WH, Meeker J et al. Pennyroyal toxicity: measurement of toxic metabolite levels in two cases and review of the literature. Ann Intern Med 1996; 124: 726–734.[Abstract/Free Full Text]

²⁵ Miller LG. Herbal medicinals. Selected clinical considerations focusing on known or potential drug–herb interactions. Arch Intern Med 1998; 158: 2200–2211.[Abstract/Free Full Text]

²⁶ Fugh-Berman A. Herb–drug interactions. Lancet 2000; 355: 134–138.[CrossRef][ISI][Medline]

²⁷ Markman M. Safety issues in using complementary and alternative medicine. J Clin Oncol 2002; 20: 39s–41s.[Abstract/Free Full Text]

²⁸ Christie VM. A dialogue between practitioners of alternative (traditional) medicine and modern (western) medicine in Norway. Soc Sci Med 1991; 32: 549–552.[CrossRef][ISI][Medline]

²⁹ Caspi O, Bell IR, Rychener D et al. The Tower of Babel: communication and medicine: an essay on medical education and complementary–alternative medicine. Arch Intern Med 2000; 160: 3193–3195.[Free Full Text]

³⁰ Paterson C, Peacock W. Complementary practitioners as part of the primary health care team: evaluation of one model. Br J Gen Pract 1995; 45: 255–258.[ISI][Medline]

³¹ Paterson C. Primary health care transformed: complementary and orthodox medicine complementing each other. Complement Ther Med 2000; 8: 47–49.[ISI][Medline]

³² New model guidelines for the use of complementary and alternative therapies in medical practice. Altern Ther Health Med 2002; 8: 44–47.[ISI][Medline]

³³ British Medical Association. Referrals to Complementary Therapists—Guidance for GPs. London: General Practitioners Committee, 1999.

³⁴ National Institutes of Health. Acupuncture. NIH Consensus Statement, 1997.

³⁵ Gordon JS. Manifesto for a New Medicine: Your Guide to Healing Partnership and Wise Use of Alternative Therapies. Reading (MA): Addison-Wesley, 1996.

³⁶ Fugh-Berman A. Alternative Medicine: What Works. A Comprehensive, Easy-to-read Review of the Scientific Evidence, Pro and Con. Tucson (AZ): Odonian Press, 1996.

³⁷ Micozzi MS (ed.). Fundamentals of Complementary and Alternative Medicine. New York: Churchill Livingstone, 1996.

³⁸ Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Puyallup (WA): Future Medicine, 1993.

³⁹ Benor DJ. Healing Research, Vol. 1. Deddington (UK): Helix Editions Ltd, 1992.

⁴⁰ Goleman D, Gurin J. Mind/Body Medicine: How to Use Your Mind for Better Health. Yonkers (NY): Consumer Reports Books, 1993.

⁴¹ National Institutes of Health. Office of Alternative Medicine. Alternative Medicine: Expanding Medical Horizons. A Report to the National Institutes of Health on Alternative Medical Systems and Practices in the United States. NIH publication no. 94-066. Washington (DC): US Government Printing Office, 1994.

⁴² Miller WL, Crabtree BF. Primary care research: a multimethod typology and qualitative road map. In Crabtree BF, Miller WL (eds). Doing Qualitative Research. Newbury Park (CA): Sage Publications, 1992: 3–28.

⁴³ Eisenberg D. Advising patients who seek alternative medical therapies. Ann Intern Med 1997; 127: 61–69.[Abstract/Free Full Text]

⁴⁴ Sierpina VS. Integrative Healthcare. Complementary and Alternative Therapies for the Whole Person. Philadelphia: F.A. Davis Co., 2001.

⁴⁵ Astin JA. Why patients use alternative medicine: results of a national study. J Am Med Assoc 1998; 279: 1548–1553.[Abstract/Free Full Text]

⁴⁶ Lininger S. A–Z Guide to Drug–Herb–Vitamin Interactions. Rocklin (CA): Prima Publishing, 1999.

⁴⁷ Ernst E. The Desktop Guide to Complementary and Alternative Medicine. St Louis: Mosby, 2001.

⁴⁸ Novey DW. Clinician’s Complete Reference to Complementary and Alternative Medicine. St Louis: Mosby, 2000.

⁴⁹ Spencer JW, Jacobs JJ. Complementary/Alternative Medicine: An Evidence Based Approach. St Louis: Mosby, 2000.

⁵⁰ Jonas WB, Levin JS. Essentials of Complementary and Alternative Medicine. Philadelphia: Williams and Wilkins, 1999.

⁵¹ Hudson T. Women’s Encyclopedia of Natural Medicine. Los Angeles: Keats, 1999.

⁵² Pizzorno JE, Murray MT. A Textbook of Natural Medicine. Seattle (WA): John Bastyr College Publications, 1998.

⁵³ Lininger S et al. The Natural Pharmacy, 2nd edn. Rocklin (CA): Prima Publishing, 1999.

⁵⁴ Murray MT. Encyclopedia of Natural Supplements. Rocklin (CA): Prima Publishing, 1996.

⁵⁵ Peirce A. The American Pharmaceutical Association Practical Guide to Natural Medicines. New York: William Morrow and Company Inc., 1999.

⁵⁶ PDR for Herbal Medicines. Montavale (NJ): Medical Economics, 2000.

⁵⁷ PDR for Nutritional Supplements. Montavale (NJ): Medical Economics, 2001.

⁵⁸ Blumenthal M et al. Herbal Medicine—Expanded Commission E Monographs. Boston (MA): Integrative Medicine Communications, 2000.

⁵⁹ Rakel D (ed.). Integrated Medicine. Philadelphia: Saunders, 2002.

CiteULike    Connotea    Del.icio.us    What's this?

This article has been cited by other articles:

				J. Kennedy, C.-C. Wang, and C.-H. Wu Patient Disclosure about Herb and Supplement Use among Adults in the US Evid. Based Complement. Altern. Med., May 17, 2007; (2007) nem045v1. [Abstract] [Full Text] [PDF]

				A. Bardia, D. L. Barton, L. J. Prokop, B. A. Bauer, and T. J. Moynihan Efficacy of Complementary and Alternative Medicine Therapies in Relieving Cancer Pain: A Systematic Review J. Clin. Oncol., December 1, 2006; 24(34): 5457 - 5464. [Abstract] [Full Text] [PDF]

				E. Ben-Arye and M. Frenkel An Approach to Teaching Physicians about Complementary Medicine in the Treatment of Cancer Integr Cancer Ther, September 1, 2004; 3(3): 208 - 213. [Abstract] [PDF]

This Article Abstract FREE Full Text (PDF) E-letters: Submit a response Alert me when this article is cited Alert me when E-letters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to citation manager Search for citing articles in: ISI Web of Science (13) Request Permissions Google Scholar Articles by Frenkel, M. A Articles by Borkan, J. M Search for Related Content PubMed PubMed Citation Articles by Frenkel, M. A Articles by Borkan, J. M Social Bookmarking          What's this?

Online ISSN 1460-2229 - Print ISSN 0263-2136

Copyright © 2008 Oxford University Press

Oxford Journals Oxford University Press

• Site Map
• Privacy Policy
• Frequently Asked Questions

Other Oxford University Press sites: Oxford University Press Oxford Journals Japan American National Biography Booksellers' Information Service Children's Fiction and Poetry Children's Reference Corporate & Special Sales Dictionaries Dictionary of National Biography Digital Reference English Language Teaching Higher Education Textbooks Humanities International Education Unit Law Medicine Music Online Products Oxford English Dictionary Reference Rights and Permissions Science School Books Social Sciences Very Short Introductions World's Classics